Emerg Med J doi:10.1136/emermed-2012-201559
  • Commentary

Life, limb and sight-saving procedures—the challenge of competence in the face of rarity

  1. Mike Clancy2
  1. 1Ambulance Service New South Wales, Bankstown, New South Wales, UK
  2. 2University of Southampton Hospital Trust, Southampton, Hampshire, UK
  1. Correspondence to Dr Cliff Reid, Great Sydney Area HEMS Ambulance Service New South Wales, 670 Drover Road, Bankstown Airport, NSW 2200, Australia; reidcg{at}
  1. Contributors Drs Cliff Reid and Mike Clancy have discussed and debated these issues with one another over the last 15 years. Mike Clancy suggested writing the article. Cliff Reid constructed the first draft. Both authors contributed to the final manuscript.

  • Accepted 17 June 2012
  • Published Online First 16 July 2012

Emergency physicians require competence in procedures which are required to preserve life, limb viability or sight, and whose urgency cannot await referral to another specialist.

Some procedures that fit this description, such as tracheal intubation after neuromuscular blockade in a hypoxaemic patient with trismus, or placement of an intercostal catheter in a patient with a tension pneumothorax, are required sufficiently frequently in elective clinical practice, that competence can be acquired simply by training in emergency department, intensive care or operating room environments.

Other procedures, such as resuscitative thoracotomy, may be required so infrequently that the first time a clinician encounters a patient requiring such an intervention may be after the completion of specialist training, or in the absence of colleagues with prior experience in the technique.

Some techniques that might be considered limb or life saving may be too technically complex to acquire outside specialist surgical training programs. Examples are damage control laparotomy and limb fasciotomy. One could, however, argue that these are rarely too urgent to await arrival of the appropriate specialist.

The procedures which might fit the description of a time-critical life, limb or sight-saving procedure in which it is technically feasible to acquire competence within or alongside an emergency medicine residency, and that cannot …

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